Emergency Contact Disclosure Statement Thank you for trusting The Michigan Assembly with the information you provide. The information on this form will be used ONLY for emergency and testing purposes. It will be kept on the mymichiganassembly.land web server for a limited time of 30 days for tests and one year for actual emergencies. The Michigan Assembly will not sell or give away your information to anyone. Contact Info Full Names of Everyone in Your Household * County * AlconaAlgerAlleganAlpenaAntrimArenacBaragaBarryBayBenzieBerrienBranchCalhounCassCharlevoixCheboyganChippewaClareClintonCrawfordDeltaDickinsonEatonEmmetGeneseeGladwinGogebicGrand TraverseGratiotHillsdaleHoughtonHuronInghamIoniaIoscoIronIsabellaJacksonKalamazooKalkaskaKentKeweenawLakeLapeerLeelanauLenaweeLivingstonLuceMackinacMacombManisteeMarquetteMasonMecostaMenomineeMidlandMissaukeeMonroeMontcalmMontmorencyMuskegonNewaygoOaklandOceanaOgemawOntonagonOsceolaOscodaOtsegoOttawaPresque IsleRoscommonSaginawSanilacSchoolcraftShiawasseeSt. ClairSt. JosephTuscolaVan BurenWashtenawWayneWexford Email * Phone * Alternate Phone PKTF Radio Number (if you have one) Your Location. Be as specific as possible. * Type of Emergency Type of Emergency * Wildfire Widespread Flooding Tornado Long-term Power Outage Ice Sleeper Cell Activated Testing Only Other Emergency Approximately how many people are affected? Nature of communication access available What is your current status? My status is… * I am safe and in need of nothing. I am OK, but could use some supplies. I am in danger! Need help ASAP. What do you need? Food Water Pet Supplies Baby food Baby Formula Diapers Blankets Transportation Shelter Fuel Generators Heaters Refrigeration Chain Saws Tarps Radios Repeaters Flotation Devices Matches/Lighters First Aid Kit Extension Cords Propane Cooking Supplies Communication Devices Clothing Medications Medical Supplies Other (if you need to add more detail of what you need) Community Organizations Offering Support Organization Name Location Support being offered plus1 Add minus1 Remove Community Organizations Needing Supplies Organization Name Location Supplies Needed Contact Phone # plus1 Add minus1 Remove Report any criminal activity Describe any criminal activity you have witnessed first hand: Upload images of evidence Drop a file here or click to upload Choose File Maximum file size: 8.39MB Anything else? Please share any additional information as desired… Submit If you are human, leave this field blank.
